. 6
( 13)


of dilute local with epinephrine is administered. This of the tip of the cannula beyond the area in¬ltrated with
facilitates the process of epidermal removal and aids in the local anesthetic-containing tumescent solution. This,
hemostasis of this very vascular plane. The area of the obviously, negates the concept of preemptive analgesia and
capsule of the breast that is the plane in which shin ¬‚aps also increases opioid requirements, intraoperative discom-
are elevated is in¬ltrated. These ¬‚aps are elevated only fort, and postoperative pain. Because there is more preci-
as necessary to accomplish proper redraping of the skin sion, less tissue trauma, and minimal opioid requirements,
around the parenchymal pedicle. It is important to ele- patients actually complain of less postoperative pain.
vate skin ¬‚aps to only within approximately 1 cm of the
pectoralis fascia. This dramatically decreases postopera-
tive pain. Any rent in the fascia, either sharply with scis-
sors or with electrocautery, or stimulation of the fascia
and underlying muscle produces signi¬cant increases in There is enough similarity between these two procedures
postoperative pain and should be avoided. to discuss proper in¬ltration of local anesthetic solutions.
Either of these procedures is combined with various ele-
ments of liposuction, and the principles outlined previ-
ously also apply in this situation. The areas of the inci-
Liposuction remains one of the most commonly per-
sions are in¬ltrated in the skin as previously described. For
formed surgical procedures in this country. For most
abdominoplasty, a skin ¬‚ap is elevated up to the level of
patients, the postoperative recovery and pain is directly
the costal margin. To facilitate abdominoplasty, tumescent
proportional to the magnitude of the procedure. In addi-
solution is in¬ltrated for vasoconstriction and preemptive
tion to the principles discussed above, it is important to
analgesia, just above the fascia in addition to any areas
adequately in¬ltrate the treated areas and allow suf¬cient
subjected to suction lipectomy (Fig. 10-7).
time for vasoconstriction. It is possible to perform fat aspi-
rations in the range of 4“6 liters or more on an outpatient
basis using these techniques. Editor™s note: Complications
increase as volumes aspirated exceed 5,000 cc. The incision
port sites are in¬ltrated with either 0.5% or 1% lidocaine
with epinephrine prior to the surgical prep. There are
several published methods for preparation of the tumes-
cent solution. Very low concentrations of epinephrine
(1:400,000“800,000) will provide adequate vasoconstric-
tion. There are also many different recommendations for
the amount of ¬‚uid instilled into each area. In general, a
1:1 ratio of in¬ltrated ¬‚uid to the volume of anticipated
fat removal is utilized. Other surgeons choose to use a
˜super-wet™ technique.
In mid-2004, Pielet started using Vaser3 Assisted Lipos- Figure 10-7. Electrocautery device use for re¬‚ection of lower
election (VAL) in addition to the standard tumescent abdominal skin ¬‚ap for abdominoplasty.
110 Rodger Wade Pielet

Once again, great care is taken to dissect the ¬‚ap slightly
above the fascia, attempting to avoid cutting or stimulat-
ing the fascia or underlying muscles. This is important
for three reasons. First, it allows visualization of vascular
perforators. They are cauterized or ligated before they can
retract into the fascia. Cut, retracted vessels complicate
the task of achieving hemostasis. Second, reduced stimu-
lation and trauma to the fascia and muscle decreases pain.
And third leaving a very thin but well-vascularized layer
of loose areolar tissue appears to decrease the incidence of
postoperative seroma formation. This is particularly help-
ful since the advent of more aggressive liposuction of the
abdominoplasty ¬‚ap and adjacent areas. The placement
Figure 10-8. Skin in¬ltration prior to incision for abdominoplasty.
of closed-suction drains is a matter of preference and the
decision is usually made intraoperatively.
The majority of postoperative pain is initially related to
Modest amounts of fat may be aspirated along with sub-
the fascial plication of the abdominal wall. There is a diver-
dermal tunneling to facilitate the dissection (Fig. 10-8).
gence of opinion as to whether or not the imbrication of the
Electrocautery may be used to develop a skin ¬‚ap which
rectus fascia, the “internal corset” of the abdominoplasty,
is elevated up to the level of the costal margin (Fig. 10-9).
requires “muscle” relaxation. Those who believe muscle
Editor™s note: Sometimes the level of analgesia from the
relaxants are required (see Chapters 11 and 13) also tend
tumescent ¬‚uid is insuf¬cient for the patient to tolerate the
to believe the rectus muscle itself is being brought to the
electrical stimulus. Supplementing the tumescent with sub-
midline. Lengthy experience with PK MAC/MIA„ tech-
fascial injection of the rectus sheath may block the perforat-
nique for abdominoplasty (see Chapters 1 and 4 ) has
ing ¬bers from the midline branch of the intercostals nerves.
reproducibly obtained adequate muscle relaxation for fas-
Additionally, it may be helpful to proceed with blunt ¬nger or
cial imbrication with adequate local analgesia. After a few
scissor dissection to develop the ¬‚ap. Lastly, one can resort to
days, most patients complain less about this area and more
an additional bolus of 50 mg ketamine to avoid abandoning
about the areas treated with liposuction.
an intravenous anesthetic; i.e. MIA„ technique (see Chapter
Formerly, multiport Accufuser catheters were placed
1) or intravenous general anesthesia (see Chapter 11).”BLF
along the fascia for postoperative pain management, but
an increase in the incidence of seromas was consistently
observed despite the use of drains. It is unlikely that this
is related to the small amount of ¬‚uid infused over time
but rather is due to the extreme effectiveness of these pain-
control devices. Essentially, the patient is extremely com-
fortable in the immediate postoperative period to such
an extent that they are excessively mobile and shearing
forces develop between the abdominal wall in the ele-
vated skin ¬‚ap. This appears to be the etiology of the
higher incidence of seromas. A slight amount of discom-
fort does lead to splinting and better effective immo-
bilization of the abdominal wall in the ¬rst few days
after surgery. The aggressiveness of the liposuction of
the lateral ¬‚ank/hip area through the abdominoplasty
incision may also facilitate seroma formation. The two
Figure 10-9. Subdermal tunneling (with possible modest liposuc-
most important factors to decrease perioperative pain
tion) prior to re¬‚ection of skin ¬‚ap for abdominoplasty.
Local Anesthetics and Surgical Considerations for Body Contouring 111

are elevation of the skin ¬‚ap just above the fascia and
placement of a 25“50 cc bolus of 0.25% bupivicaine in the
fascia and the incision prior to closure.
The thigh lift, both medial and lateral, essentially in-
volves extensive tumescent liposuction, blunt dissection,
and mild elevation of skin ¬‚aps. All of these techniques
were outlined earlier in this chapter.


In addition to the breast augmentation and pectoral aug-
mentation discussed previously, there has been a consider- Figure 10-10. The entire pocket is elevated and corresponds
precisely to the preoperative markings. This technique aids in
able increase in the number of requests for both calf aug-
hydrodissection, elevation of the plane, hemostasis, and periop-
mentation as well as buttock augmentation. In essence, erative pain management.
the dissection for calf augmentation is entirely above the
gastrocnemius muscle through an incision in the popliteal
fossa. Again, the incision line is injected prior to surgical
infragluteal incision as well as a single midline incision.
preparation and a small amount of dilute local and aes-
Pielet prefers bilateral paramedian incisions, as they seem
thetic is injected into the subcutaneous space where the
to yield the most acceptable cosmetic and functional result.
implants are to be placed. This is often performed as a
Dissection is carried down to the muscle and a subepime-
purely cosmetic procedure with the placement of one or
sial plane is dissected. Rather than injecting a bolus of local
two implants on each side. It is also performed as a uni-
anesthetic into the respective pocket, sequential aliquots
lateral procedure in individuals with either developmental
of dilute lidocaine with epinephrine are injected into the
or traumatic asymmetry.
undulating epimesium between the muscle ¬bers (see
There are many different approaches for buttock
Fig. 10-10).
augmentation. Some surgeons prefer a supragluteal or

11 Intravenous Anesthesia for Cosmetic Surgery
David Barinholtz, M.D.

Alpha 2 Agonists
Nonopioid Analgesics
Nonsteroidal anti-in¬‚ammatory drugs (NSAIDs)
Adjunct Agents
Who™s at Risk?
Types of PONV
Prevention and Treatment of Immediate PONV
Nonpharmacologic Therapy
Prevention and Treatment of Delayed PONV
Preoperative Care”Prior to the Day of Surgery
Preoperative Care”Day of Surgery
Intraoperative Care
Postoperative Care

Intravenous Anesthesia for Cosmetic Surgery 113

years to deem SpO2 a standard of care. Capnography
became a standard of care, dramatically reducing the inci-
In the 1840s came the ¬rst case reports of successfully dence of unrecognized esophageal intubations. The adop-
anesthetizing patients for surgical procedures. The agents tion of these two innovations, along with a large in¬‚ux of
used were inhalational agents, speci¬cally diethyl ether and very highly trained anesthesia providers into the profes-
nitrous oxide. Crawford Long, Horace Wells, and William sion, is widely believed to be responsible for the dramatic
T. G. Morton will forever be credited with bringing the reduction in anesthetic-related mortality.4 By the mid-
bene¬ts of anesthesia to patients undergoing surgery.1,3 1990s, anesthetic-related mortality rates had decreased to
No longer would surgical patients needlessly suffer. In this approximately 1 in 250,000.5
era, the only ways to deliver an anesthetic systemically Another seminal event in the late 1980s that revolution-
was by inhalation or ingestion (hollow needles had not ized anesthesia, especially ambulatory anesthesia, was the
yet been invented). Inhalation agents provided a rapid, introduction of propofol.6 Propofol was the ¬rst (and still
reliable, predictable way to anesthetize patients compared the only) rapid, ultra“short-acting sedative/hypnotic with
with ingesting alcohol and/or opiates. Hollow needles were a lack of cumulative effects.7 Propofol could be admin-
introduced in the late 1800s. istered continuously for prolonged anesthetics and still
Although various injectable adjuncts such as opiates, allow patients to awaken rapidly without prolonged som-
sedative/hypnotics, dissociative agents, and muscle relax- nolence (or “hangover”).8,9 It is this quality, as well as an
ants were developed in the early and mid 20th century, inherent antiemetic effect, that has made propofol such a
inhalation agents (i.e., nitrous oxide and the halogenated popular agent for outpatient anesthesia.
ether derivatives such as halothane, ethrane, iso¬‚urane) By the mid-1990s, anesthesia care was extremely safe
were the mainstays of anesthesia until the 1980s. How- and reliable, especially for healthy people having outpa-
ever, they were far from ideal. Inhalation agents (volatile) tient surgery. The most popular anesthetic technique was
are fraught with a myriad of side effects, such as myocar- the “balanced” anesthetic. This technique takes advantage
dial depression, hypotension, arrhythmias, and postoper- of the utility of volatile agents combined with intravenous
ative nausea and vomiting (PONV). Anesthesia was very agents for analgesia and muscle relaxation. Most of these
risky until the 1980s. The combination of cardiovascular patients were intubated, paralyzed, and mechanically ven-
effects of inhalation agents, the routine use of muscle relax- tilated. Although this technique is safe and reliable, it has
ants, and lack of sophisticated monitoring devices other its limitations. Prolonged effects of volatile agents (even
than ECG, NIABP, and spirometry (in addition to the ¬n- des¬‚urane and sevo¬‚urane), muscle relaxants, and opi-
ger on the pulse, stethoscope, and direct observation) was oids caused prolonged recovery times and a high incidence
the underlying reason. Anesthetic-related death rates were of undesirable side effects such as PONV. Also, analgesia
generally quoted in the 1-in-10,000 range. With millions was totally dependent on systemic opioids. Surgeons and
of anesthetics being performed annually, the main focus anesthesiologists were at odds about the use and safe doses
of the anesthesia community was to improve patient safety of local anesthetics (see Chapter 8). Systemic NSAIDs
as opposed to minimizing undesirable side effects such as were reported by some to increase hematoma formation.
prolonged anesthetic effects and PONV. Loss of NSAID analgesia meant increased reliance on opi-
Many things happened in the 1980s to revolutionize oids and opioid-related PONV. There had to be a better
anesthesia care. The ¬rst commercially marketed pulse way.
oximeter, the Nellcor N-100, was introduced in 1984. Pulse In 1997, Barinholtz left the hospital-based anesthesia
oximetry dramatically reduced the incidence of adverse world. After ¬ve years in academic anesthesia, the rapidly
hypoxic events. Not until 1990 did the ASA deem pulse expanding area of of¬ce-based anesthesia captured his
oximetry a “standard of care.” It was intuitively obvious to interest. Armed with the same knowledge as his colleagues,
early technology adapters that knowing the patient™s state Barinholtz set out to develop an anesthesia practice out-
of oxygenation instantaneously was in¬nitely preferable side of the hospital setting that took advantage of all the
to relying on clinical signs and/or blood gases. Nonethe- technologic and pharmacologic advances to provide the
less, it was most disappointing that it took the ASA six safest state-of-the-art of¬ce-based anesthesia practice. For
114 David Barinholtz

the ¬rst time in his career, Barinholtz began to question THE IDEAL ANESTHETIC
everything he did and why he did it. Does every patient
For more than 150 years, the professionals who have ded-
need to be intubated? Does every intubated patient need to
icated their careers to caring for people during one of the
be paralyzed? Are intravenous agents (e.g., propofol) bet-
scariest, most stressful and anxiety-provoking experiences
ter than volatile agents? Is a 20% PONV rate acceptable?
of their lives have strived to do so with caring, compassion,
Are some of the techniques Barinholtz administered more
and above all safety.
for his convenience than for the best interest of the
What would the ideal anesthetic look like? In a per-
fect world, the ideal anesthetic would have the following
Some of Barinholtz™s ¬rst clients were plastic surgeons.
When he ¬rst started working with them in their of¬ce-
based surgical suites, he soon discovered that providing 1. SAFE”0% morbidity/mortality rate.
a safe anesthetic wasn™t good enough. The “standard” 2. QUICK”minimum of time to achieve the desired
propofol induction, LMA placement, maintenance with effect and wear off just as rapidly.
sevo¬‚urane while judiciously titrating fentanyl, and a 3. EASY/RELIABLE”simple to administer and have
dose of droperidol, was safe and reliable. Most patients very predictable effects.
were discharged in less than two hours. Frequently, res- 4. EMERGENCE”wear off quickly without undesir-
cue antiemetics and opioids were being administered in able side effects.
recovery. The biggest complaints were related to PONV 5. ANALGESIC”pain-free experience.
and pain management. Better outcomes were demanded! 6. AMNESTIC/SEDATIVE/HYPNOTIC (same cate-
The cosmetic surgery patient is not like a typical “elec- gory because patients make no distinction among
tive” surgical patient. The cosmetic surgery patient isn™t the three)”from a patient™s perspective, as long as
having surgery for a medical condition. These patients they have no memory of anything they don™t desire
desire to look better and expect to feel better. A patient to remember perioperatively, it makes no difference
having surgery for a medical condition is most con- to them if they were actually completely asleep.
cerned about getting better. In contradistinction, a cos- 7. NO MOVEMENT”although this may not be the
metic surgery patient will tend to be highly critical of every largest preoccupation from an anesthesiologist™s
aspect of care preoperatively, intraoperatively, and post- point of view, it is the single largest issue for a
operatively, in addition to the achievement of the desired surgeon. Patients talking during their surgery is
cosmetic result. Once through this process, the cosmetic an additional issue. Whereas a patient may not be
surgical patient will ultimately answer the question, “Was aware or care if they are babbling incessantly during
it worth it?” A rocky perioperative course due to anesthe- surgery, it is very distracting and will upset even the
sia can re¬‚ect poorly on the surgeon. Conversely, a won- most tolerant surgeon.
derful anesthetic experience will re¬‚ect very positively on
No one agent or technology will achieve all seven of
the surgeon and the anesthesia provider. Optimizing every
these objectives. However, application of the current phar-
aspect of anesthetic care, from the preoperative evalua-
macologic agents and anesthetic monitoring technologies
tion through the postoperative follow-up, became the new
comes very close.
What follows is the distillation of eight years of expe-
rience in of¬ce-based elective cosmetic surgery. What
evolved was a propofol-based, intravenous anesthetic,
guided by neurophysiologic monitoring, with minimal The best argument for an intravenous anesthetic reg-
airway intervention and judicious use of local anesthet- imen is that one has independent control over every
ics. Based on vastly improved PONV rates and minimal anesthetic variable. Balanced anesthesia or TIVA relies
postoperative pain management, Barinholtz™s approach on hypnosis augmented by the addition of analgesics
provides an anesthetic for the cosmetic surgery patient and muscle relaxants. In contrast, an inhalational anes-
superior to the former “standard” (vide supra). thetic provides hypnosis, analgesia, and a degree of muscle
Intravenous Anesthesia for Cosmetic Surgery 115

relaxation as an all-in-one package. A sedative/hypnotic and dexmetetomidine, which provide excellent anxiol-
such as propofol will provide only unconsciousness and/or ysis, the role of benzodiazepines is being called into
amnesia. Dissociative agents (e.g., ketamine) and/or opi- question.
oids will provide systemic analgesia. If a small amount
of skeletal muscle relaxation is necessary for a rectus
Alpha2 Agonists
muscle repair, for example, a small, subparalyzing dose
of a short-acting nondepolarizing agent (e.g., rocuro-
Although developed as an antihypertensive agent, cloni-
nium) provides the desired effect without paralyzing the
dine has attracted the interest of the anesthesia commu-
diaphragm, avoiding the need for intubation and positive
nity for many years. Over the past ¬fteen years, clonidine
pressure ventilation. Adjuncts such as intravenous anti-
has been administered by intravenous, epidural, spinal,
cholinergics, antiemetics, and vasoactive agents such as
and intra-articular routes.14’18 Clonidine accentuates and
labetolol, esmolol, and ephedrine provides unparalleled
spares concomitantly administered anesthetic agents.19,20
control over every aspect of anesthetic effect and side
Clonidine is particularly well suited for use in cosmetic
effect. More recently utilized agents, such as the centrally
surgery patients.21,22 Its sedative and anxiolytic effects
acting alpha2 agonists clonidine and dexmetetomodine,
make it an ideal preoperative agent, obviating the need
promise to improve the anesthetic even more. In order to
for midazolam. Its sedative and analgesic effects help min-
optimize the anesthetic, neurophysiologic monitoring for
imize propofol usage,23’25 as well as opioids, thus mini-
depth of anesthesia and liberal use of local analgesia are
mizing PONV. Its prolonged antiadrenergic effect helps
control blood pressure perioperatively, thus theoreti-
cally minimizing chances of hematomas postoperatively.
Clonidine has some limitations and concerns, however.
Administered orally (usually in the 0.1“0.3 mg range),26,27
it must be given thirty to sixty minutes prior to surgery.
Once given, the dose cannot be titrated. Although gener-
For many years, preoperative administration of diazepam
ally predictable, the desired de facto tranquilizing effect
for anxiolysis and perioperative amnesia was a mainstay
is not always achieved. Clonidine 0.2 mg will achieve
of most anesthetic regimens. In more recent years, the
a 2.5“5.0 ug · kg’1 blood level in patients weigh-
more potent, shorter-acting, and more amnestic midazo-
ing between 95“175 pounds. De facto tranquilization is
lam replaced diazepam. For many, midazolam is still part
nearly always achieved with a therapeutic dose. Alter-
of virtually every anesthetic. Although a reliable amnes-
natively, sometimes the effect is more dramatic than
tic, it does have its drawbacks. In an elegant Level 1
desired, requiring increased perioperative ¬‚uids and occa-
study, Oxorn10 demonstrated a lack of propofol sparing
sional use of adrenergic agents to support blood pressure
effect with 2 mg midazolam premedication in a nono-
(Table 11-1).
pioid anesthetic. Oxorn reported that midazolam has an
antianalgesic effect.10,11 When administered PO for pedi-
atric patients, even for propofol/sevo¬‚urane-based anes-
thetics it can be the rate-limiting factor in recovery.12 For This centrally acting alpha2 agonist, FDA-approved for
GI procedures, the use of even modest doses of mida- sedating ICU patients, is eight times more potent than
clonidine.28 Recently, Mayer29 at the University of Illi-
zolam, with or without opioids, can result in prolonged
nois and Shapiro30 at Harvard have been involved in
sedation and/or amnesia. Patients often cannot recall
results discussed with the gastroenterologist after the pro- clinical trials in the perioperative use of dexmetetomi-
cedure. In contrast, patients receiving propofol, without dine. This rapidly acting (approximately ten minutes),
benzodiazepines, for these procedures not only remember short-acting, intravenous agent shows great promise in
outpatient anesthesia.28 Currently, however, its use is
results discussed postoperatively but also recover much
more quickly. With the more widespread adminstration cost-prohibitive in the price-sensitive world of cosmetic
of centrally acting alpha2 agonists such as clonidine13 surgery.
Table 11-1. Anesthetic agents for total intravenous anesthesia (TIVA)

Class Drug Site-of-action Principal effect Role in component therapy

Benzodiazepines Midazolam Bdz/gaba receptors Amnesia/anxiolysis/sedation Preoperative anxiolytic/amnestic
Clonidine (exists in PO/IV form Anxiolysis/sedation/analgesia Preoperative anxiolytic
Alpha2 agonists Alpha2 receptors in CNS
usually administered PO) decreases adrenergic output intraoperative sedation/
Dexmetetomodine (8X more Anxiolysis/sedation/analgesia Preoperative anxiolytic
Alpha2 receptors in CNS
potent than clonidine IV infusion) decreases adrenergic output intraoperative
Sedative/hypnotic Propofol Cerebral cortex Sedation/unconsciousness Main sedative/hypnotic/volatile
Dissociative agent Ketamine NMDA receptors Dissociation/analgesia Dissociative/analgesic
Opioids Fentanyl Narcotic Systemic analgesia Systemic analgesia
Sufentanil Receptors
Rein Sentanil
NSAIDs Ketorolac COX-2s Cyclooxygenase Anti-in¬‚ammatory analgesia Limited because of antiplatelet
Celecoxib, Rofecoxib, Valdecoxib inhibitors effect recent concerns with
(all oral except valdecoxib-IV) COX-2s
Para-aminophenol Acetaminophen Inhibits central Analgesia Limited 2—¦ to limited effectiveness
derivatives prostaglandin synthesis and hepatotoxic concerns
Intravenous Anesthesia for Cosmetic Surgery 117

Propofol bene¬ts of more local over increasing anesthetic depth will
be worth the very modest amount of time required to do so.
In 2007, no discussion of anesthesia for cosmetic surgery
Barinholtz™ surgeons don™t view PONV as a large prob-
can be complete without including propofol. A deriva-
lem. If PONV were a large problem for plastic surgeons,
tive of isopropylphenol, propofol has single-handedly rev-
they would acquiesce to attempts to minimize if not elim-
olutionized outpatient anesthesia. With propofol as the
inate opioids. However, Macario™s studies have shown
principal anesthetic agent, aided by judicious use of small
PONV is a large issue for patients.
amounts of opioids and ketamine and guided by neuro-
With aggressive antiemetic strategies (vide infra),
physiologic monitoring, a reliable TIVA is possible. In
patients experience approximately 1% incidence of PONV
Barinholtz™s practice, every cosmetic procedure, from
in the immediate postoperative period. Nonetheless, elim-
facelifts to abdominoplasties to breast reductions to prone
ination of PONV is only one reason to eliminate opioids.
liposuction, is performed with a propofol-based anesthetic
The addition of systemic analgesia transforms deep seda-
with no more airway intervention than an oropharyngeal
tion into intravenous general anesthesia. Opioids depress
airway. The success of this technique depends on the clin-
the laryngeal or “life-preserving” re¬‚exes thereby increas-
ical vigilance of the anesthesiologist as well as neurophys-
ing the probability of aspiration. Opioids depress respi-
iologic monitoring and local anesthetics.
ration mandating the routine administration of supple-
Ketamine mental oxygen and monitoring of EtCO2. Supplemental
oxygen is a ¬re hazard in the presence of lasers and electro-
Developed in the 1960s and popularized as a pediatric
cautery devices particularly around the face. Lastly, opioids
and veterinary anesthetic agent, ketamine was largely over-
fail to block noxious input to the brain from the surgical
looked for use in cosmetic surgery until recently (see Chap-
ters 1 and 4).
Interestingly, virtually all of the PONV that occurs in
Historically, large doses of ketamine administered to
pediatric and trauma patients (2“4 mg · kg’1 ),31 fre- these patients happens after taking postoperative opioids
at home (i.e. postdischarge or PDPONV). The surgeons
quently without amnestics such as midazolam, resulted
could certainly minimize patient calls related to PONV as
in profound dysphorias and/or hallucinations. Because of
well as to pain if they adopted more local-analgesia-based
unpredictable outcomes, ketamine fell out of favor with
strategies, both intra- and postoperatively (vida infra).
anesthesiologists (vide supra).
Opioids will continue to be part of Barinholtz™ anesthetic
In the 1990s, some began mixing smaller amounts of
ketamine with propofol with impressive results.32,33 Total practice for the foreseeable future. However, the follow-
doses of ketamine of less than 1 mg · kg’1 administered ing technique has evolved to speci¬cally minimize opioid
requirements for all types of cosmetic surgery.
by bolus or continuous infusion in the presence of ade-
quate propofol thynosis attenuates the response to local
Nonopioid Analgesics
anesthetic injections and minimizes opioid requirements.
In fact, PK MAC in the presence of clonidine premed- There are primarily two types of nonnarcotic analgesics
ication, BIS-monitored propofol to 60“75, and adequate used for the purposes of preventing and treating periop-
local anesthesia obviates the need for opioids altogether.34 erative pain.

Unfortunately, in Barinholtz™ practice, despite the use of A derivative of para-aminophenol, acetaminophen is
clonidine and ketamine in conjunction with propofol, the effective as an antipyretic and analgesic for mild to mod-
complete elimination of opioids has not been possible. erate pain. Commonly used to treat headaches and mild
The surgeons, although adept at administering local anes- arthritic pain, its role in cosmetic surgery is limited. The
thetic agents for the most part, aren™t perfect. Plastic sur- maximum recommended dosages are not very effective
geons take exception to interrupting surgery to administer in preventing or treating pain associated with cosmetic
procedures.35 Exceeding the maximum doses can be hep-
more local. Rather, they insist on increasing the depth of
the anesthetic. Perhaps, with more surgeon education, the atotoxic and is not recommended.
118 David Barinholtz

Nonsteroidal anti-in¬‚ammatory drugs (NSAIDs) (Celebrex r ) is the only commercially available COX-2
The prototypical NSAID, ibuprofen, has been used for inhibitor. It is not as effective as either rofecoxib or valde-
many years as an effective analgesic for even moderate to coxib for postoperative pain, and there are now concerns
regarding this whole class of drugs.49 It is probably most
severe pain. In addition to its analgesic effect, ibuprofen
is a potent anti-in¬‚ammatory. Anti-in¬‚ammatory action prudent at this time to avoid their routine use periopera-
is an especially desirable feature that keeps swelling to a tively until more research is done.
minimum after dental/oral surgery as well as facial cos-
metic procedures. In the late 1980s, an injectable NSAID,
Adjunct Agents
ketoralac, was introduced. The use of this drug soared.
Table 11-2 summarizes adjunct agents utilized in compo-
It appeared that eliminating opioids was ¬nally possible.
nent intravenous anesthesia. These agents are used mainly
However, case reports began to appear in the surgical liter-
to offset effects of the previously-mentioned agents.
ature of postoperative bleeding complications linked to the
Glycopyrrolate is administered to minimize secretions,
use of ketorolac (as well as other NSAIDs).36,39 Whether
especially when using ketamine. The adrenergic agents
a justi¬ed indictment or not, most cosmetic surgeons will
(ephedrine or epinephrine) can be used to offset the car-
not allow their patients to take NSAIDs within two weeks
diovascular effects of propofol, opioids, and, occasionally,
of surgery (before or after), let alone administer them peri-
clonidine. The beta-blockers (and alpha/beta-blockers)
can be used to offset effects of epinephrine (from local
In the mid-1990s, a subclass of NSAIDs was devel-
anesthetic injections) and cocaine. Titrated judiciously,
oped.40 The cyclooxygenase subtype 2 inhibitors (COX-2)
one can avoid signi¬cant tachycardia, bradycardia, hyper-
take advantage of the fact that there are different types of
tension, or hypotension (Table 11-2).
prostaglandins mediating in¬‚ammation and coagulation.
Two subtypes of cyclooxygenase act on arachadonic acid to
form prostaglandins. By inhibiting cyclooxygenase-2 (and
not cyclooxygenase-1), the prostaglandins that are respon- Virtually every cosmetic surgical procedure performed in
sible for pain and in¬‚ammation are not formed. How- an of¬ce-based setting is conducted with a spontaneously
ever, the prostaglandins responsible for proper platelet breathing, nonintubated patient. Muscle relaxants are not
function, formed through the action of cyclooxygenase- routinely utilized, except in one speci¬c instance. Specif-
1, are uninhibited. The result is an NSAID that treats pain ically, rocuronium is administered for the rectus muscle
and in¬‚ammation without inhibiting platelet function. repair portion of an abdominoplasty.
Celecoxib was the ¬rst FDA-approved COX-2 inhibitor, Nondepolarizing muscle relaxants inhibit the nicotinic
though it was originally developed to treat arthritis pain cholinergic receptors at the neuromuscular junction in
without analgesia. Next, rofecoxib (Vioxx r ) proved even direct competition with acetylcholine relative to the con-
more effective for postoperative pain.41,45 Many practi- centration at the site. Different muscle groups have vary-
tioners, even cosmetic surgeons, began adopting the use ing concentrations of cholinergic receptors. Therefore,
of rofecoxib perioperatively because it eliminated the fear it is possible to partially paralyze some muscles with-
of bleeding complications. Results were promising. Then, out affecting others in a clinically signi¬cant way (e.g.,
an even more potent COX-2 inhibitor, valdecoxib, was relaxing some muscles without completely paralyzing the
introduced speci¬cally for postoperative pain. The results patient). Because the muscle with the highest concentra-
of clinical trials were impressive comparing valdecoxib.46 tion of cholinergic receptors is the diaphragm, it requires
An injectable form of valdecoxib, parecoxib, was in phase the highest concentration of nondepolarizing agent to par-
3 clinical trials and showed promise as a convenient peri- alyze it. A dose of rocuronium exists that will effectively
operative analgesic.47 relax the rectus muscle for surgical repair without affecting
Unfortunately, in 2004, amid reports of cardiac deaths diaphragmatic function. The ideal dose is approximately
associated with the chronic use of Vioxx r , Merck removed 25% of an intubating dose (or 10 mg of rocuronium for a
it from the market.48 As more data surfaced, valde- 70-kg adult). Administered a few minutes prior to muscle
coxib was also voluntarily withdrawn. Currently, celecoxib repair, it gives the surgeon ideal circumstances (virtually
Table 11-2. Adjunct agents

Class Drug Site-of-action Principal effect Role in compotent therapy

Anticholinergic Glycopyrrolate Muscarinic receptors Antisialogogue Drying agent
Steroid Dexamethasone Cells medating in¬‚ammation CNS Anti-in¬‚ammatory antiemetic Anti-in¬‚ammatory antiemetic

Butyrophenones (dopaminergic Droperidol Dopamine receptors Antiemetic Antiemetic
Ondansetron Antiemetic Antiemetic
5HT3 antagonists 5HT3 receptors
Beta-blockers Esmolol B-adrenergic receptors Decrease heart rate Decrease heart rate response to
epinephrine in local and /or
Alpha and beta blockers Labetolol Alpha and beta adrenergic Decrease heart rate decrease Offset effects of epinephrine
receptors blood pressure and/or cocaine
Adrenergic agent Ephedrine Direct beta agonist indirect alpha Increase heart rate increase blood Offset hypotensive effects of
and beta agonists CNS pressure antiemetic anesthesia antiemetic
Adrenergic agent Epinephrine Direct alpha and beta agonist Increase heart rate increase blood Offset hypotensive effects of
pressure anesthesia
Nondepolarizing muscle Rocuronium Nicotinic-cholinergic receptors Muscle relaxation Relax rectus muscle for repair

120 David Barinholtz

identical to conditions encountered in the intubated, par-
alyzed, positive-pressure ventilated patient) to complete
the repair. Since rocuronium is so short acting and there is
usually at least one hour between the muscle repair and the
conclusion of surgery, it has not been necessary to adminis-
ter reversal agents. Also, this technique avoids a completely
paralyzed patient and the associated risks (airway, DVTs,
awareness). Muscle relaxation, not paralysis, is adminis-
tered. In hundreds of cases done with this technique in
the past eight years, no patient has required intubation or
become paralyzed at these doses. Succinylcholine (SCH)
is available in Barinholtz™s practice, but its use is relegated Figure 11-1. The airway continuum.
to that of an emergency drug only.
The remaining adjunct agents are addressed in the sec-
tion on antiemetics. to offer most of the advantages of endotracheal intubation
without the invasiveness. However, all are deeply situated
in the pharynx (stimulating all the pharyngeal re¬‚exes).
A 15 mm breathing connection facilitates coupling to an
anesthesia breathing circuit and, ultimately, an anesthe-
The area of anesthesia that causes some of the most con- sia machine. Does the patient always need a supraglottic
troversy and is a signi¬cant factor in anesthetic-related device situated deep in the pharynx in order to maintain an
morbidity and mortality is airway management. Prior airway during deep sedation? Do all airway devices require
to the invention of the cuffed endotracheal tube (ET) a 15 mm connector? The answer to these questions is no.
by Guedel,50 patients were not routinely intubated for One method to explain and illustrate the concept is to
surgery. Along with the ET and the discovery of mus- introduce the airway continuum (see Fig. 11-1). The con-
cle relaxants,51 routine intubation with paralysis even for tinuum is simply a line that from left to right represents
minor surgeries became commonplace.52 Mask ventila- increasing airway invasiveness. On the left is the untam-
tion, especially for short procedures such as myringotomy pered natural airway and on the right is the most invasive
and cystoscopy, was still common. However, by the early airway intervention, tracheostomy. In between are nasal
1990s, the overwhelming majority of patients receiving cannulae, oral and nasal airways, the supraglottic devices,
general anesthesia were intubated with an endotracheal and endotracheal tubes. The continuum is divided into left
tube. and right halves. The right half is the side on which all the
In the early 1990s, a revolutionary airway device was devices have a 15 mm connection for a breathing circuit.
introduced in the United States. Developed by Brain in These devices have the advantage of attaching to a fresh gas
Great Britain, it was called the laryngeal mask airway source, the ability to monitor end-tidal CO2 , and provid-
(LMA).53,54 This device gave practitioners an intermediate ing the ability for positive-pressure ventilation. However,
choice between mask ventilation and endotracheal intu- the presence of a 15 mm connector and the absence of
bation. Over the past ¬fteen years, the LMA has gained opioids means that patients can breathe, with or without
widespread acceptance worldwide, especially in the ambu- supplemental oxygen, spontaneously through a supraglot-
latory anesthesia arena. The LMA gives practitioners the tic device without being connected to an anesthesia circuit.
ability to maintain a patient™s airway, reliably deliver oxy- Less is more.
gen (and other gases), and monitor end-tidal CO2 , all with- The left half essentially comprises nasal cannulae, oral
out the need for paralysis. Its success has spurred a host of airways, and nasal airways. Whereas nasal cannulae attach
similar devices claiming similar advantages, for example, to an oxygen source, traditionally oral airways and nasal
the cuffed oropharygeal airway (COPA r ) and laryngeal trumpets don™t. Also, none of these devices conveniently
Combitube. Both the COPA r and the Combitube r claim provides the ability to monitor end-tidal CO2 .
Intravenous Anesthesia for Cosmetic Surgery 121

Figure 11-3. Patient with modi¬ed oral airway in place for rhyr-
Figure 11-2. Patient with modi¬ed oral airway in place for prone

procedures include blepharoplasty, endoscopic browlift,
Recently, nasal cannulae that simultaneously deliver
rhytidectomy, rhinoplasty, breast augmentation, breast
oxygen and provide for end-tidal CO2 monitoring
reduction, mastopexy, abdominoplasty, body lift, and lipo-
have become commercially available. Several years ago,
suction (including prone and lateral cases) (see Fig. 11-2,
Mallinkrodt patented a device fashioned as a nasal trum-
11-3, and 11-4). This device facilitates the maintenance of
pet with the ability to administer oxygen and sample CO2 .
a patent airway, the reliable delivery of oxygen, and the
One can fashion an oral airway device that can simultane-
reliable monitoring of end-tidal CO2 (see Fig. 11-5).
ously deliver oxygen and sample end-tidal CO2 . Figure 11-
There are two potential criticisms. First, this device does
2 shows a standard Guedel oral airway, ¬‚anges trimmed to
not protect the airway. Second, one cannot immediately
allow placement behind the teeth, with two lengths of oxy-
ventilate the patient if necessary. These criticisms are valid
gen tubing placed into the opening in the airway: a short
and underscore the importance of choosing appropri-
length situated distally in the airway that can easily attach
ate candidates without anticipated airway dif¬culty and
directly to a male adapter for end-tidal CO2 monitoring,
who are not at risk for aspiration (i.e., GERD). Also, one
and a longer length with the standard 5 in 1 connector,
must have the personnel, drugs, supplies, and equipment
or “Chistmas-tree” adapter, compatibility to attach to an
(including Ambu r bag, intubation equipment, LMAs,
oxygen ¬‚owmeter. In the past six years, this device has been
cricothyroidotomy kit, and jet ventilator) to deal with
employed in thousands of cosmetic procedures. These

Figure 11-4. Patient with modi¬ed oral airway in place for breast Figure 11-5. Modi¬ed oral airway with tubing to sample CO2 and
augmentation, breast reduction, mastopexy or abdominoplasty. deliver oxygen.
122 David Barinholtz

every airway eventuality as described in the ASA dif¬cult- ing the issue of “awareness under [general] anesthesia.”
airway algorithm.55 Properly prepared, there is no reason The more germane issue for of¬ce-based as well as other
every skilled anesthesia provider cannot reproduce Barin- anesthesiologists is the much more common occurrence
holtz™s success in applying this technique. No patient has of overanesthetizing patients. However, patients have also
suffered a serious complication with resulting harm from heard the stories of awareness under anesthesia. Dozens of
its application in Barinholtz™s practice. accounts from patients of their own experiences (or those
of a close friend or relative) have been related to Barinholtz.
He is frequently asked how he can “make sure” this won™t
happen to them. The fact that patients are not paralyzed or
intubated is of great reassurance to them. Routinely mon-
itoring with BIS is an additional source of reassurance.
Since its ¬rst practical applications more than 150 years
The techniques described in this chapter rely on intra-
ago, anesthesia care has had three main goals, namely,
venous anesthesia in spontaneously breathing, nonpara-
(1) make patients unconscious/unaware of the gruesome
lyzed, nonintubated patients. Awareness is not a signi¬-
experience of having surgery, (2) immobilize the patient
cant concern as these patients can move (or even talk) if
so the surgeon can operate, and (3) don™t kill the patient.56
they want or need to do so. Despite the fear of undermedi-
Historically, issues such as pain control and PONV pre-
cating, the much more likely (and common practice) issue
vention were distant to these fundamental concerns.
is that of overanesthetizing.
While great strides have been made Because the 1840s
Overmedicating produces more undesirable anesthetic
in all three of these areas, a review of the improvements
side effects (e.g., hypotension) intraoperatively, more
of the past ¬fty years is appropriate. Approximately ¬fty
PONV, prolonged recoveries, and wasted drugs. In Barin-
years ago, curare, and subsequently, its derivatives, came
holtz™s anesthesia practice, all drugs, supplies, and equip-
into clinical use. For procedures that require immobility,
ment are the anesthesiologist™s responsibility. Further-
there is a speci¬c drug, receptor, and monitoring model.
more, the anesthesia provider must be physically present
As far as anesthetic mortality, the necessary technologies
until all patients are recovered and discharged. It makes not
have been developed to directly monitor and address the
only good clinical sense but good business sense to employ
concerns germane to this issue, speci¬cally, ECG, NIABP,
neurophysiologic monitoring. In the seven years since
SpO2 , and EtCO2 (Fig. 11-6).
employing BIS monitoring, propofol usage has decreased
However, between 1842 and 1996, there was no way
by 20%. Patients rarely spend more than one hour recov-
to directly monitor the patient™s level of unconsciousness.
ering, even after a prolonged (six-hour) anesthetic. The
There has been an overwhelming amount of attention in
foundation of the anesthetic care provided to Barinholtz™s
the anesthesia community, as well as the lay press, regard-
cosmetic surgery patients is the utilization of the TIVA
technique in conjunction with BIS monitoring.
Finally, directly monitoring the effects the anesthetics
have on the target organ”the brain”is more accurate
than indirect indices of anesthetic depth. The historically
used, indirect (and frequently inaccurate) cues to assess
depth of anesthesia such as heart rate, blood pressure,
tearing, and patient movement are no longer as relevant to
decision making as is the measure of the cerebral cortical
level of hypnosis (see Chapter 3).
Development of the BIS (and similar competing tech-
nologies, such as PSA 4000 and Entropy) and re¬n-
ing the technology (i.e., the BIS-XP platform) are
great advancements for anesthetic care. Anesthesiologists
Figure 11-6. Monitor screen during sedation with modi¬ed oral
should embrace BIS monitoring. Although BIS is not
airway. N.B. True end-tidal CO2 tracing.
Intravenous Anesthesia for Cosmetic Surgery 123

a perfect technology, neither is ECG, NIABP, or pulse postoperative hypertension secondary to pain (again, min-
oximetry. BIS provides valuable, reliable, reproducible imizing the risk of a hematomata). This results in happier
data to help guide anesthetic care. Certainly, monitoring patients and happier surgeons who aren™t getting called as
the EEG effects of anesthesia makes more sense than recent often. If a surgeon can effectively numb the area they are
attempts to develop technologies to monitor and main- operating on and operate without extending beyond the
tain ¬xed blood concentrations of anesthetic agents.57,58 anesthetized area (or with a willingness to administer more
A given concentration of agent in the blood may still have local during the procedure if necessary), it is possible and
a wide range of clinical effects on different patients. It is highly desirable to anesthetize the patient without using
important to monitor the effect on the brain directly (see any opioids (vide supra and see Chapter 4). But even in
Chapter 3). the situation where a surgeon doesn™t maximize the use of
local (a predicament in which many anesthesiologists ¬nd
themselves), the liberal use of lidocaine greatly facilitates
minimizing intraoperative drug consumption, especially
opioids. The only caveat is to not exceed maximum safe
Administering propofol and ketamine, supplemented by
doses of local anesthetics (see Chapter 8 on lidocaine toxi-
alpha2 agonists and opioids, can provide a TIVA with-
city and Chapters 9 and 10 on local analgesia techniques).
out relying on local analgesia. However, this is not an
advisable approach to the care of the cosmetic surgery
patient. Intraoperatively, one would have to anesthetize
the patient much more deeply. Although ketamine can
The single biggest concern expressed by patients under-
be used to provide some analgesia, opioids could not be
going anesthesia for cosmetic surgery (or all surgery, for
avoided. Postoperatively, pain relief would be completely
that matter) is the fear of PONV. Studies have shown that
dependent on opioids. Prolonged recoveries, high PONV
when questioned, patients indicate that the fear of PONV
rates, and inadequate (certainly suboptimal) pain relief
is greater than the fear of postoperative pain and other
would be the outcome. In order for the patient to have
anesthetic side effects.63,64 Given the choice, most patients
an optimal experience, adequate local analgesia must be
would rather deal with pain than nausea and vomiting.
PONV doesn™t occur just when the patient is under the
Years ago, it was a struggle to get surgeons to employ
anesthesiologist™s direct care. Patients are at risk for PONV
local analgesia as part of the surgical procedure. How many
into the postdischarge, postoperative period, especially if
anesthesiologists have heard their surgeon say, “Why do I
the surgeon has prescribed opioids for postoperative pain.
need local? That™s what you™re here for.” Luckily, today™s
In order for the patient to have a PONV-free experience,
enlightened cosmetic surgeon knows that employing local
one must have a rational, organized approach for both
analgesia is a valuable and necessary adjunct for the ulti-
prevention and treatment of PONV, should it occur.
mate success of the surgery. The concept of preemptive
analgesia is well established in both the anesthesia and
surgical literature.59“62 Who™s at Risk?
Postoperative local analgesia is achieved by using a long- Theoretically, every patient receiving anesthesia is at risk
acting local anesthetic, such as bupivicaine, in the opera- of PONV. Over the years, characteristics and risk factors
tive ¬eld before closing. Alternatively, placing a continuous have emerged that identify patients who are at a higher
infusion of local anesthetic postoperatively in the form of risk of experiencing PONV. These are (1) female gender,
one of many commercially available pain-pumps will min- (2) nonsmokers, (3) previous history of PONV, (4) hav-
imize, if not eliminate, the requirement for opioids. ing a surgical procedure associated with a higher incidence
Treating postoperative pain with local anesthetics, instead of PONV (e.g., gynecologic, laparoscopic, strabismus,
of opioids, results in more effective pain relief. and various cosmetic procedures, especially of the face),
The patient is made more mobile (minimizing risks of (5) history of motion sickness, (6) exposure to volatile
thromboembolic phenomena), less prone to PONV and anesthetic agents, and (7) exposure to opioids (Table 11-3).
postoperative hematomata, and less likely to experience Several authors have attempted to assign point values to
124 David Barinholtz

Prevention and Treatment of Immediate PONV
Table 11-3. Risk factors for PONV
In order to determine if the patient is at risk of immediate
PONV, delayed PONV, or both, focus on key elements of
1. Female gender
2. Nonsmoker the history. Patients with a previous history of PONV need
3. Young age to be questioned carefully as to when the PONV occurred.
4. Previous history of PONV
Did it occur in the recovery room, on the way home, or
5. Emetogenic procedure
after the patient returned home? Did it occur after taking
6. History of motion sickness
7. Volatile anesthetic agents oral opioids for pain? Did they follow the instructions and
8. Opioids
make sure to have a full stomach before taking oral opioids?
Did it linger for days after surgery? Does the patient have a
history of motion sickness (putting them at risk for PONV
each of these risk factors in an attempt to assess an individ- on the ride home)? The answers to these very speci¬c
ual patient™s relative risk of experiencing PONV. Although questions can help the practitioner determine when and
no model is perfect, clearly the more of these risk factors where the patient is most at risk for developing PONV
that apply to an individual patient, the higher his or her and help arrive at a speci¬c plan for both prevention and
risk of PONV.65,68 treatment.
Because the overwhelming majority of the cosmetic Table 11-4 lists speci¬c factors that put patients at more
surgery patients in Barinholtz™s practice are female non- risk for immediate PONV. A previous history of imme-
smokers who will most likely receive opioids intra- and diate PONV or an emetogenic procedure automatically
postoperatively (many of whom have a history of PONV makes the patient at higher risk. Adding volatile agents
and motion sickness), all of these patients are treated as and/or opioids further increases the risk.
at being high risk for PONV. Because of this proactive, The most effective strategy for these patients is to make
aggressive effort to prevent it, the PONV rate in Barin- certain they™re well hydrated (follow the ASA guidelines
holtz™s practice is less than 1%. and not only allow but encourage clear liquids up to three
hours before surgery), avoid volatile agents, and avoid opi-
oids. Whereas the ¬rst two admonitions are easy to accom-
Types of PONV plish, unfortunately opioids cannot always be avoided. If
a cosmetic surgery patient who is considered high risk
PONV can be separated into two types, immediate
for immediate PONV receives opioids, he or she should
and delayed. Immediate PONV occurs immediately after
also receive multimodal therapy.69 Inspired by the works
surgery and during the recovery phase while the patient
of Scuderi, White, Gan, and Chung, it makes sense that
is still under the direct care of the anesthesia provider.
utilizing small doses of different classes of antiemetics to
Delayed PONV occurs after the patient has been dis-
disrupt the nausea/vomiting pathway at different points
charged. This could occur on the way home or up to several
will yield a higher success rate with a lower incidence of
days postoperatively. Learn to distinguish between these
side effects (e.g., dysphoria, somnolence, or tardive dysk-
two and develop strategies for prevention and treatment
inesia) than monotherapy.
of both. There are some guiding principles common to
Whereas Scuderi et al. describe various “cocktails,” the
both types of PONV.
one Barinholtz employs has been utilized clinically in the
The ¬rst is that prophylaxis is better than treatment. It
treatment of more than 3,000 cosmetic surgery patients
is far more desirable to prevent the problem altogether than
over the past ¬ve years. Low-dose droperidol (0.625 mg
to have to deal with the consequences.
for the average adult) and dexamethasone (10 mg for the
The second is that avoidance of opioids is the single
average adult) shortly after induction, followed by low-
largest factor in preventing PONV.
dose ondansetron (1 mg for the average adult) at the con-
Any or all of the strategies discussed herein can suc-
clusion of the procedure, are administered.
cessfully deal with PONV 99% of the time. If opioids are
The Barinholtz “cocktail” has been 99% effective in
somehow avoided, approximating 100% PONV-free out-
the prevention and treatment of immediate PONV in his
comes could be achieved with less prophylaxis.
Intravenous Anesthesia for Cosmetic Surgery 125

practice and is very cost effective for routine use. In the rare
instance of PONV in the PACU, additional ondansetron
(1 mg or 4 mg orally dissolving tablet [ODT r ]) is gener-
ally effective. Another effective approach can be to admin-
ister 50 mg IM ephedrine. This is effective even in the
normotensive patient. The effect appears to be centrally
mediated. Ephedrine “perks” up the patients and is usually
effective within ten to ¬fteen minutes after administration.
Pay close attention to these patients as they begin to
move around, stand up, get dressed, and walk. If the
therapy is effective and they remain nausea-free during
the getting-ready-to-leave phase, the patients can be dis-
charged without further therapy (as long as there are not
additional risk factors for delayed PONV). If, however, the
patient is still nauseated despite all of the above, further
therapy is required.

Nonpharmacologic Therapy
An effective adjunct to pharmacologic therapy is P6 accu-
point stimulation. Based on the principles of acupunc-
ture and backed by impressive clinical results in several
recent studies,70,71 stimulation of the P6 accupoint has
been shown to be very effective in the prevention and treat-
ment of PONV (as well as nausea/vomiting secondary to
motion sickness, pregnancy, and chemotherapy). Located
on the inside of the wrist, approximately 1 inch below the
palmar crease, in the distribution of the median nerve, the
P6 accupoint is easily identi¬able. Whereas some authors
Figure 11-7. Reliefband.
have chosen to needle the P6 accupoint or apply pressure in
order to stimulate it, the most effective practical approach
is electrostimulation. The Reliefband r (Abbott Laborato-
the patient to continue at home for up to several days
ries) is the only device currently available and approved by
postoperatively if necessary.
the FDA for electrostimulation of the P6 accupoint for the
prevention and treatment of PONV (as well as nausea and
Prevention and Treatment of Delayed PONV
vomiting from pregnancy, motion sickness, or chemother-
apy).70,71 Reliefband r see Fig. 11.7 is easy to use, patient Table 11-4 outlines speci¬c factors that put a patient in
controlled, and portable, and Barinholtz has employed it the high-risk category for delayed PONV. These are a pre-
as an adjunct to (or, in some cases, replacement of) phar- vious history of delayed PONV, a history of motion sick-
macologic agents for PONV for more than ¬ve years. In ness, a history of ineffective (or questionable) treatment of
patients with resistant PONV, or in whom pharmocologic immediate PONV, and any prescription for oral opioids
agents are contraindicated, or in patients at risk of delayed for postoperative pain. For patients in this category, have
PONV, Reliefband r has been a very clinically effective a strategy that is practical for home therapy. The options
as well as cost-effective approach in Barinholtz™s practice. are pills, orally dissolving tablets (ODTs), suppositories,
Combined with 5-HT3 antagonists (e.g., ondansetron), and P6 accupoint stimulation (vide supra).
it has been shown to be remarkably effective.72 Also, the Patients do not generally favor suppositories. Pills can
combination of Reliefband r and ondansetron is easy for be hard to swallow in the face of active PONV. Also, some
Table 11-4. Assessing risk and strategies for prevention and treatment of PONV

Risk factors Prevention Treatment

Immediate Previous history immediate PONV Make sure patient is well hydrated Additional pharmacologic agents”consider
PONV Emetogenic procedure preoperatively (encourage clear liquids nonpharmacologic therapy (P6 accupoint
Exposure to volatile anesthetic up to 3 hours before surgery) stimulation)
Intraoperative and/or postoperative Avoid volatile agent
opioids Avoid (or at least minimize) opioid usage
Multimodal pharmacologic therapy
Delayed PONV Previous history delayed PONV Make sure immediate PONV resolved Prescribe PO antiemetic
History of motion sickness before discharging patient Consider nonpharmacologic therapy
Prescription for oral opioids for postop Instruct driver on careful driving (especially
pain in patients with history of motion
Ineffective treatment of immediate PONV sickness)
Avoid postoperative opioids (employ local
anesthetics for postop pain)
Reiterate need for full stomach before
PO opioids
Intravenous Anesthesia for Cosmetic Surgery 127

Preoperative Care”Prior to the Day of Surgery
of the drugs historically prescribed in pill form have many
undesirable side effects. Prochlorperazine (Compazine r ) After assessing a patient™s health status and determining
can cause dysphoria, somnolence, restlessness, and whether the patient is an appropriate candidate for elec-
extrapyramidal symptoms like tardive dyskinesia. Tardive tive, outpatient cosmetic surgery, the ¬rst step in caring for
dyskinesia is particularly distressing because the highest the patient is to make direct contact. Speak directly with the
incidence of this unpleasant side effect appears to occur patient before the day of surgery to assess risk and give pre-
in elderly women. Traditionally, elderly women comprise operative instructions. Address any questions or concerns
a high percentage of rhytidectomy patients. Primum non the patient may have. This ¬ve- to ten-minute encounter
nocere (First, do no harm). Make sure the cure is not worse (almost always by phone) can have a dramatic anxiolytic
than the disease. effect and actually reduce anesthetic requirements. It can
Antihistamines (e.g., diphenhydramine) are effective also help avoid delays on the day of surgery. Issues gen-
but also cause undesired somnolence (of course, the anti- erally discussed are concerns about being awake during
histamines are sedative-sparing, don™t cross the blood- surgery (a frequently asked question in Barinholtz™s prac-
brain barrier, and are thus ineffective as antiemetic. Bar- tice), putting risk in perspective (driving in a car is riskier
inholtz does, however, occasionally recommend diphen- than receiving anesthesia), and assuring that issues such
hydramine to patients with PONV who are also trying to as postoperative pain and PONV will be addressed. With
get to sleep). The most effective drug treatment with the the interview, assess the risk of PONV (immediate and/or
fewest side effects are the 5-HT3 antagonists. However, this delayed) and discuss the strategy.
can become quite expensive. Pharmacies charge approxi-
Preoperative Care”Day of Surgery
mately $25 (in 2005 dollars) for one 4 mg Zofran ODT. r
Patients may need this for many postoperative days. This On the day of surgery and after time is spent making sure
therapy could cost hundreds of dollars. However, some preoperative instructions were followed (including NPO
prescription plans will cover this expense. Employing P6 instructions and assurance of responsible adult escort),
accupoint electrostimulation with a Reliefband r may be the patient is prepared for surgery. In addition to start-
a more cost-effective solution. A disposable, prescription ing the IV, it is at this time that clonidine (usually 0.2
Reliefband r (which many prescription plans also cover) mg po) is administered. It is important that the patient
costs about $100 and will last twenty-four hours per day arrive at least thirty minutes prior to entering the OR to
for up to six days. Utilizing one or both therapies is very take the clonidine. If clonidine is contraindicated (e.g.,
effective in almost all patients. because the patient is hypotensive preoperatively), a small
The best way to avoid delayed PONV is to avoid postop- amount of benzodiazepine (1“2 mg midazolam IV) may be
erative opioids altogether. administered for anxiolysis, if necessary, prior to entering
Employing adequate local analgesia intraoperatively the OR.
and postoperatively (in the form of a continuous local
Intraoperative Care
anesthetic infusion with a commercially available, dispos-
able pain pump) is the most effective way to achieve this Upon entering the OR and after placement of monitors
goal. (ECG, NIBP, pulse oximeter, BIS), anesthesia is induced.
If a patient did not receive clonidine or preoperative
midazolam, a small dose of midazolam can be admin-
istered at this time. This is usually followed by a small
dose of fentanyl (50“75 ug IV) and a propofol bolus.
The principles of TIVA for cosmetic surgery have been dis- Propofol is administered and titrated to the BIS while
cussed. A real case scenario follows. In detail, the preop- oxygen is being administered blow-by via the modi-
erative and postoperative care of a prototypical cosmetic ¬ed oropharyngeal airway (lidocaine 1%, 1cc per 10cc
surgery patient is examined. This technique is relatively of propofol is mixed in with the initial syringe of
generic in caring for patients having virtually any cosmetic propofol to reduce burning). When the BIS is between
procedure, in any operative position. 40 and 50, the patient will tolerate placement of the
128 David Barinholtz

oropharyngeal airway (usually somewhere between 1 and three to ¬ve minutes of discontinuation of propofol. With
2 mg · kg’1 of propofol has been administered by this BIS >80, the patient will open his or her eyes and respond
time). to commands.
After placement of the oropharyngeal airway and con- At this time the patient is transferred to a recliner and
¬rmation of a patent airway by end-tidal CO2 tracing, taken to the PACU. Propofol is generally consumed at a
rate of approximately 50 cc · hr’1 for the average patient.
ketamine (usually 50 mg IV) is administered. Two to
three minutes after ketamine administration, the surgeon Opioid administration varies widely depending on patient
may inject the local analgesia. In addition to assuring the characteristics (e.g., history of smoking or drinking), pro-
ketamine has taken effect, BIS is usually maintained in cedure (nature and length), and surgeon™s skill with local.
the range of 40“50 with the propofol infusion, and small If the procedure is one that historically is associated
doses (25 ug increments) of fentanyl are administered and with signi¬cant postoperative pain (i.e., abdominoplasty
titrated to a respiratory rate of approximately ten breaths or subpectoral breast augmentation), the surgeon will fre-
per minute (easily monitored by observing the end-tidal quently utilize a local anesthetic pain pump signi¬cantly
CO2 tracing) before the surgeon is allowed to inject the local decreasing, if not eliminating, the need for opioids post-
analgesia. This (i.e., GA) will assure a virtually immobile operatively.
patient for local injections. Obviously, additional boluses
of propofol and/or fentanyl may occasionally need to be
Postoperative Care
administered (guided by BIS and respiratory rate, respec-
Once in PACU, patients are observed, postoperative issues
tively). If one decides to administer additional ketamine,
(i.e., pain, PONV) are addressed as necessary, and the
make sure the total dose doesn™t exceed 1 mg · kg’1 . Higher
patients are discharged to go home in the company of
doses may be associated with undesirable side effects such
a responsible adult escort. Most patients (more than 90%)
as dysphoria, prolonged recovery, and even PONV.
arrive in PACU with an Aldrette score of 9 or greater, thus
Once the surgery is underway (and appropriate antibi-
putting them in phase recovery. It is the rare patient in
otics have been administered if necessary), the BIS is
Barinholtz™s practice that spends more than one hour in
allowed to come up and is generally maintained at 60
(+/’10) for the remainder of the procedure.
As part of the postoperative instructions and follow-up,
Prophylactic antiemetics are administered. At this point,
Barinholtz takes on the burden of addressing postanes-
and for the remainder of the procedure, the propofol infu-
thetic complications directly. Patients and/or their fami-
sion is titrated according to the BIS. Usual infusion rates are
lies are instructed to call the anesthesia provider if there
75“120 ug · kg’1 · min’1 , but rates as low as 25 ug · kg’1
are anesthetic-related issues such as PONV. The surgeons
· min’1 or as high as 300 ug · kg’1 · min’1 are some-
greatly appreciate this. Luckily, by employing these tech-
times required. The ability to respond to this patient
niques, calls are rare.
variation underscores the importance of BIS monitoring.
Additional opioids are titrated to achieve or maintain a
respiratory rate of ten to ¬fteen breaths per minute. Close
communication with the surgeon and close attention to
the surgery must be maintained in order to be able to Of¬ce-based anesthesia has come a long way since
respond to the more and less stimulating parts of the Dr. Crawford Long successfully administered the ¬rst ether
procedure by adjusting the propofol infusion and opi- anesthetic in 1842. Advances in pharmacology and tech-
oid boluses accordingly. If muscle relaxation is required nology have made anesthesia better and safer than ever.
for rectus muscle repair, utilize the technique described It is now a rare event (especially for healthy people hav-
earlier. ing elective cosmetic surgery) for patients to suffer their
When the surgeon is placing the last stitches (or plac- demise under the anesthesiologist™s care. Improving the
ing the garment on the patient), the propofol infusion is quality of the perioperative experience has become a pri-
discontinued. Low-dose ondansetron is administered. The mary focus. In the future, with better drugs, better mon-
patient is allowed to awaken, which occurs typically within itoring technologies, and better delivery systems, further
Intravenous Anesthesia for Cosmetic Surgery 129

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12 Regional Anesthesia for Cosmetic Surgery
Holly Evans, M.D., F.R.C.P., and Susan M. Steele, M.D.

General Assessment
Special Consideration: Coagulation Abnormalities
Sedation for Block Placement
Intraoperative Sedation
Indications and advantages
Local anesthetics and adjuvants
Adverse effects
Indications and advantages
Local anesthetics and adjuvants
Adverse effects
Paravertebral Nerve Blocks
Indications and advantages
Local anesthetics and adjuvants
Adverse effects
Intercostal Nerve Blocks
Indications and advantages
Local anesthetics and adjuvants
Adverse effects

132 Holly Evans and Susan M. Steele

ations are performed. In addition, the site where regional
Table 12-1. Goals of anesthesia for
anesthesia is to be administered is inspected. Laboratory
cosmetic surgery
investigations are performed based on the patient™s under-
Intraoperative analgesia lying medical problems and the anticipated surgery. For
Intraoperative anxiolysis ( ± amnesia) example, an otherwise healthy thirty-year-old woman hav-
Postoperative analgesia
ing breast augmentation may require no preoperative test-
Absence of postoperative side effects (nausea,
ing. A sixty-year-old woman with hypertension treated
vomiting, sedation, urinary retention)
Early return of baseline cognitive abilities with a diuretic would be appropriately investigated with
Timely postoperative discharge
electrolytes and an electrocardiogram prior to her
abdominoplasty. Similarly, consultations with other med-
ical specialists may be required for active medical issues.
The physiologic effects of regional anesthesia must be con-
sidered in the context of the patient™s underlying medical
Anesthesia for patients undergoing cosmetic surgery must condition(s) (Table 12-2). Subsequently, potential con-
accomplish a number of important goals (Table 12-1). traindications to regional anesthesia as well as ambulatory
Regional anesthesia, which includes both central neurax- surgery must be sought and addressed (see Tables 12-3,
ial techniques as well as peripheral nerve blocks, has a 12-4, and 12-5). Ideally, the preoperative anesthesia assess-
commendable safety pro¬le1 and unique attributes that ment is performed several days prior to the scheduled pro-
allow these goals to be met. Nerve blocks provide dense cedure to enable such consultation, patient optimization,
intraoperative anesthesia and analgesia. This minimizes and rescheduling if required.
requirements for additional anesthetic, analgesic, or seda- The preoperative visit provides an ideal time for patient
tive agents; consequently, side effects such as postopera- education. Patients are instructed about fasting guidelines,
tive nausea, vomiting, and sedation can be minimized.2,5 which medications to take the day of surgery, and the tim-
This enhances patient recovery and discharge and may also ing of medications and herbal remedies to be discontinued
improve patient satisfaction.6,8 Peripheral nerve blocks preoperatively (see Ch. 14 & Appendix A). Outpatients
with long-acting local anesthetic can extend the duration should be noti¬ed that they require a responsible care-
of postoperative analgesia and further minimize opioid giver to accompany them to and from surgery and to stay
use and associated side effects.2 This chapter describes the with them the night of surgery. In the process of obtain-
use of central neuraxial blocks and peripheral nerve blocks ing informed consent for anesthesia, patients should be
in cosmetic surgical patients. A discussion of appropriate educated about the expected intra- and postoperative
preoperative evaluation, monitoring, sedation, and nerve
block technique, as well as postoperative recovery and dis-
charge, is included.
Table 12-2. Physiologic effects
of neuraxial anesthesia
Cardiovascular Sympathectomy
General Assessment Vasodilation
Evaluation of patients contemplating regional anesthesia Hypotension ( ± bradycardia)
Respiratory With high block:
should include a full history and physical examination
Subjective dyspnea
as well as investigations or consultations as indicated. A
Impaired active exhalation
complete history is obtained to document active medi- Impaired cough
cal issues, past medical history, prescription and nonpre- Gastrointestinal Increased secretions
Sphincter relaxation
scription medication use, allergies, and personal and fam-
Bowel constriction
ily anesthesia history. The physical examination involves Endocrine-Metabolic Inhibition of surgical stress
assessment of the patient™s height, weight, vital signs, and response


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